Papilledema
1. Definition
- Papilledema
= optic disc swelling จาก ↑ intracranial pressure (ICP) เท่านั้น
- ต่างจาก:
- optic
disc edema (สาเหตุอื่น เช่น ischemia, inflammation)
2. Etiology ของ ↑ICP (high-yield)
กลุ่มหลัก
- Brain
mass (tumor, hemorrhage)
- Cerebral
edema (trauma, hypoxia)
- CSF
flow obstruction →
hydrocephalus
- Venous
outflow obstruction (CVT)
- Idiopathic
Intracranial Hypertension
- Rare:
CSF overproduction
3. Pathophysiology
- ↑ICP → pressure transmitted via subarachnoid space
- → block axoplasmic flow
- → optic disc swelling
- → late: axonal damage → vision loss
4. Clinical Features
Key concept:
👉 Vision มักปกติใน early stage (สำคัญมาก)
Symptoms
- Transient
visual obscurations (seconds–minutes)
- Headache
(↑ with Valsalva)
- Nausea/vomiting
- Diplopia
(CN VI palsy)
- Pulsatile
tinnitus
Vision loss
- Late
finding
- เริ่มจาก:
- enlarged
blind spot
- peripheral
constriction
5. Fundoscopic Findings (progression)
Early
- blurred
disc margin (inferior/superior →
nasal → temporal)
- hyperemia
- venous
congestion
- absent
venous pulsation
Established
- disc
elevation
- flame
hemorrhage
- cotton
wool spots
- Paton
lines
- loss
of cup
Chronic →
Atrophic
- pale
disc
- gliosis
- optic
atrophy → permanent
vision loss
6. Key Differentiation (สำคัญมากใน practice)
|
Feature |
Papilledema |
Optic neuritis |
NAION |
|
Vision early |
Normal |
↓ |
↓ |
|
Pain |
❌ |
✅ |
❌ |
|
Laterality |
Bilateral |
Uni |
Uni |
|
RAPD |
Late |
Early |
Early |
|
VF |
blind spot |
central |
altitudinal |
7. Papilledema Mimics (ต้องแยก)
7.1 Optic disc drusen
- pseudopapilledema
- no
hemorrhage / congestion
7.2 Hypertensive optic neuropathy
- BP สูงมาก
- retinal
ischemia signs
7.3 Non-Arteritic Anterior Ischemic Optic Neuropathy
- vision
loss ตั้งแต่แรก
- disc
pallor
7.4 Optic neuritis
- pain
+ vision loss
7.5 Neuroretinitis
- macular
star
8. Diagnostic Approach (ER priority)
Step 1: Confirm papilledema
- Bilateral
disc edema
- Vision
relatively preserved
Step 2: Immediate evaluation
- BP
measurement (exclude malignant HTN)
- Neuro
exam
Step 3: Imaging (urgent)
- MRI
brain + contrast
- ±
MRV (suspect venous sinus thrombosis)
Step 4: Lumbar puncture (after imaging)
- Measure
opening pressure
- CSF
analysis
👉 cutoff:
- 25
cmH₂O (adult) = abnormal
9. Additional Tools
- Ocular
ultrasound → ↑ optic nerve sheath
diameter
- Visual
field → blind spot
enlargement
- OCT → monitor edema /
differentiate drusen
10. Management
Principle:
👉 Treat underlying
cause + ลด ICP
Options
- Mass → surgery
- Hydrocephalus
→ CSF diversion
- IIH:
- weight
loss
- acetazolamide
- Refractory:
- CSF
shunt
- venous
sinus stent
- optic
nerve sheath fenestration
11. Prognosis
- Early:
reversible
- Late
(atrophic stage):
- permanent
vision loss
12. Key Clinical Pearls
- Papilledema
= neurologic emergency until proven otherwise
- Vision
preserved early = clue สำคัญ
- Always
imaging ก่อน LP
- Bilateral
disc edema ≠ papilledema เสมอ (ต้องแยก mimic)
- Blind
spot enlargement = early VF defect
- RAPD
→ คิด diagnosis
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